Order Refills

THE VIKING OFFICE WILL RECEIVE AND EVALUATE YOUR REFILL REQUEST. IF APPROVED, THE PAYMENT INFORMATION SPECIFIED WILL BE CHARGED AND THE ORDER PROCESSED AND SUBMITTED TO THE PHARMACY.
Date
MM slash DD slash YYYY
Email*
Enter Email Confirm Email
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Drivers License Number
State
Requested refill for the following medications:*
Note: If a medication is outside of your already approved protocol you will need to schedule a consultation before we can send any new medication. ALSO: It is required that your lab results be less than 6 months old at all times. Please schedule labs prior to refill order if needed!
Billing Address*
***We cannot ship to a PO Box - we need an actual street address in order to ship your medication. ***

Street Address Address Line 2 City State ZIP Code
Is your shipping address the same as billing address?
- Yes
***We cannot ship to a PO Box - we need an actual street address in order to ship your medication. ***
Shipping Address*
Street Address Address Line 2 City State ZIP Code

***We can only ship to your residential address. We cannot ship to a PO Box - we need an actual street address in order to ship your medication. ***
Pay with Cryptocurrency
- YES
- NO
Cardholder's Name
Credit Card
Card Type
- American Express
- Discover
- Mastercard
- Visa
- HSA
Expiration Date
Expiration Year
Security Code

THE VIKING OFFICE WILL RECEIVE AND EVALUATE YOUR REFILL REQUEST. IF APPROVED, THE PAYMENT INFORMATION SPECIFIED WILL BE CHARGED AND THE ORDER PROCESSED AND SUBMITTED TO THE PHARMACY.